Rosen & Barkin's 5-Minute Emergency Medicine Consult (607 page)

• Treat hypoperfusion with IV NS
  
• Packed RBC for blood loss or anemia after lack of response after 2 boluses
  
• Invasive cardiac monitoring if unable to assess cardiac failure vs. hypovolemia
  
• Response to NS good indicator of the degree to which hypovolemia is a factor
  

• Glomerulonephritis:
  
  • Glucocorticoids or plasma exchange
    
• ATN:
  
  • Volume replacement
    
• Hyponatremia: Free water restriction
  
• Hyperkalemia:
  
  • Sodium polystyrene sulfonate (SPS) or calcium polystyrene sulfonate (CPS) for asymptomatic patient with K
    ⁺
    >5.5 mEq/L
    
  • For K
    ⁺
    >6.5 mEq/L or ECG abnormalities consistent with hyperkalemia:
    
    • Albuterol via nebulizer
      
    • Dextrose and insulin
      
    • Furosemide if patient not anuric
      
    • Calcium stabilizes myocardium in severe hyperkalemia
      
    • Calcium gluconate for awake patient
      
    • Calcium chloride for patient without pulse
      
    • Dialysis for intractable hyperkalemia
      
• Metabolic acidosis:
  
  • Consider sodium bicarbonate for pH <7.2 or HCO
    ₃
    <15 mEq/L in
    chronic disease
    
  • Hyperphosphatemia:
    
    • Calcium carbonate
      
    • Aluminum hydroxide
      
  • Myoglobinuria—aggressive fluid resuscitation with NS
    

• Albuterol: 10–20 mg via nebulizer
  
• Aluminum hydroxide (amphojel): 0.5–1.5 g PO
  
• Calcium carbonate (Os-Cal): 0.250–3 g PO
  
• Calcium gluconate: 10 mL of 10% solution over 5 min IV (may repeat q5min)
  
• Calcium chloride: 10 mL of 10% solution
  
• Dextrose: D
  ₅₀
  W 1 amp (50 mL or 25 g) (peds: D
  ₂₅
  W 2 mL/kg) IV
  
• Furosemide: 20–400 mg IV push
  
• Insulin: 0.1 U/kg regular IV with dextrose (decrease dose by 50% for severe renal and/or liver disease)
  
• Sodium bicarbonate: 1–2 mEq/kg IV
  
• SPS (Kayexalate) or CPS: 1 g/kg up to 15–60 g PO or 30–50 g retention enema in sorbitol q6h
  

FOLLOW-UP

• New-onset AKI
  
• Hyperkalemia/significant electrolyte abnormalities
  
• Fluid overload with hypoxia/congestive heart failure
  
• Uremia
  
• Altered mental status
  

• Stable
  
• Normal electrolytes
  

Refer to primary physician for progressive AKI in an otherwise stable patient.

• Insulin dose for hyperkalemia should be reduced for significant liver or renal disease so as to avoid hypoglycemia.
  
• NSAIDs to be avoided with any degree of AKI
  
• SPS has a considerable sodium load; CPS is preferred when volume overload is a concern.
  
• Avoid contrast if possible in AKI, as it may worsen renal function.
  

• Andreoli S. Acute kidney injury in children.
  Pediatr Nephrol
  . 2009;24:253–263.
  
• Kellum JA. Acute kidney injury.
  Crit Care Med
  . 2008;36(suppl):S141–S145.
  
• Rahman M, Shad F, Smith MC. Acute kidney injury: A guide to diagnosis and management.
  Amer Fam Physician
  . 2012;86(7):631–639.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Hyperkalemia
  
• Renal Injury
  

CODES

• 584.5 Acute kidney failure with lesion of tubular necrosis
  
• 584.9 Acute kidney failure, unspecified
  
• 997.5 Urinary complications, not elsewhere classified
  

BASICS

• Kidneys are located in the retroperitoneal space and are surrounded by adipose tissue and loose areolar connective tissue.
  
• Kidneys lie along the lower 2 thoracic vertebrae and 1st 4 lumbar vertebrae.
  
• Left kidney is positioned slightly higher than the right.
  
• Kidneys are not fixed:
  
  • Shift with the diaphragm and are supported by the renal arteries, veins, and adipose tissue to the renal (Gerota) fascia
    

• Most common of all urologic injuries
  
• Occurs in ∼8–10% of all abdominal trauma
  
• Blunt renal trauma accounts for 80–85% of all renal injuries and is 5 times more common than penetrating injury:
  
  • Mechanisms include motor vehicle accidents, falls, domestic violence, and contact sports.
    
  • Pathophysiology includes rapid deceleration and displacement mechanisms.
    
  • ∼20% of cases are associated with intraperitoneal injury.
    
• Mechanisms responsible for significant renal injury almost never affect the kidney alone:
  
  • Most often disrupt and injure other vital organs that can be responsible for patient mortality
    
• Renal injuries are graded by type and severity of injury (Association for the Surgery of Trauma [AAST] criteria)
  
  • Grade I
    
    • Contusion: Microscopic or gross hematuria, urologic studies normal
      
    • Hematoma: Subcapsular, nonexpanding without parenchymal laceration
      
  • Grade II:
    
    • Hematoma: Nonexpanding, perirenal hematoma confined to retroperitoneum
      
    • Laceration: <1 cm parenchymal depth of renal cortex without urinary extravasation
      
  • Grade III
    
    • Laceration: >1 cm parenchymal depth of renal cortex without collecting system rupture or urinary extravasation
      
  • Grade IV:
    
    • Laceration: Parenchymal laceration extending through renal cortex, medulla, and collecting system
      
    • Vascular: Main renal artery or vein injury with contained hemorrhage
      
  • Grade V:
    
    • Laceration: Completely shattered kidney
      
    • Vascular: Avulsion of renal hilum, devascularizing the kidney
      

• The kidney is the organ most commonly damaged by blunt abdominal trauma.
  
• Contributing factors:
  
  • Relatively larger size of kidneys compared with adults
    
  • 10th and 11th ribs are not completely ossified until the 3rd decade of life.
    
• Significant abdominal injury occurs in about 5% of nonaccidental trauma cases but is the 2nd most common cause of death after head injury.
  

DIAGNOSIS

• Mechanism of injury and kinematics are important factors.
  
• Majority of renal injuries are associated with injury of other abdominal organs.
  
• In blunt trauma, note the type and direction (horizontal or vertical) of any deceleration or compressive forces.
  
• In penetrating trauma, note the characteristic of the weapon (type and caliber), distance from the weapon, or the type and length of knife or impaling object:
  
  • Injuries result from a combination of kinetic energy and shear forces of penetrating object.
    

• Hematuria is the best indicator of traumatic urinary system injury:
  
  • Severity of renal trauma does not correlate with the degree of hematuria.
    
  • Absence of hematuria does not exclude renal injury
    
• Microscopic hematuria with a systolic BP <90 mm Hg
  
• Flank mass or ecchymosis
  
• Tenderness in the flank, abdomen, or back
  
• Fracture of the inferior ribs or spinal transverse processes
  
• Nausea and vomiting